instruction

Instructions for CCC-941
AVERAGE ADJUSTED GROSS INCOME (AGI) CERTIFICATION AND
CONSENT TO DISCLOSURE OF TAX INFORMATION
This certification and consent to disclosure statement is to be used for the
certification of compliance with the $900,000 AGI limitation applicable to 2011
through 2023 crop, program, and fiscal year benefits.
The completion of this form also allows access to and the use of the participant’s tax
information on file at the IRS as required by USDA to verify a program participant’s
compliance with the adjusted gross income (AGI) limitation for the receipt of commodity,
conservation and price support program benefits. See page 2 of the form for definitions
and eligibility requirements.
Submit this completed form to the FSA county office or USDA Service Center at the
address specified in Item 1.
Complete Items 1 through 3; Review Part A and complete Items 4 and 5; then Review Part
B and complete Items 6 through 8.
Items 1 - 3 Basic Information
Field Name /
Item No.

Instruction

1
County FSA
Office or USDA
Service Center
Address
2
Person or Legal
Entity’s Name
and Address

Enter the name , address and fax number of the county Farm
Service Agency or USDA Service Center office where the
completed form will be submitted.

3
Taxpayer ID No.

In the format provided, enter the complete social security or tax
identification number of the person or legal entity identified in
Item 2.

Enter the person’s or legal entity’s name and address for
commodity, conservation and price support program benefits.
Enter the name and address as it appeared on the IRS tax
returns filed for the taxable years specified in Item 4.

Part A – Certification of Average Adjusted Gross Income
4
Enter the year for which program benefits are being requested.
Program Year
The program year entered determines the 3-year period used for
the calculation of the average adjusted gross income (AGI)
amount for payment eligibility purposes and the years for
which this consent allows access to tax information.
Page 1 of 2

(As of: 10-01-21)

Field Name /
Item No.
5
Average
adjusted gross
income

Instruction
Select the box next to the response that describes the average
adjusted gross income for the applicable 3-year period that
corresponds to the year entered in Item 4. (Select only one
response).

Part B – Consent to Disclosure of Tax Information
6
Signature

7
Title or
Representative
8
Date

Page 2 of 2

Read the acknowledgments, responsibilities and
authorizations, before affixing signature.
For all types of legal entities, this form must be signed by a
duly authorized representative under applicable state law.
If signing in a representative capacity for the individual or legal
entity in Item 2, please include the title or relationship.
Enter the signature date in month, day and year
(MM-DD-YYYY).

(As of: 10-01-21)